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Treatment as Prevention (TasP) Dr Michael Brady Medical Director, Terrence Higgins Trust Consultant, HIV & Sexual Health.

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Presentation on theme: "Treatment as Prevention (TasP) Dr Michael Brady Medical Director, Terrence Higgins Trust Consultant, HIV & Sexual Health."— Presentation transcript:

1 Treatment as Prevention (TasP) Dr Michael Brady Medical Director, Terrence Higgins Trust Consultant, HIV & Sexual Health

2 Reducing onward transmission: Viral suppression among key population groups living with HIV in the United Kingdom. 19th Annual Conference of the British HIV Association (BHIVA) April 2013, Valerie Delpech, Alison Brown, Stephano Conti, Venkata Polavarapu, Zing Yin

3 3 Efficacy 0% % Effect size (95% CI) Tenofovir/Truvada for discordant couples 73% (49; 85) Study Medical male circumcision 54% (38; 66) Prime boost Vaccine 31% (1; 51) 39% (6; 60) Tenofovir vaginal (coital) Truvada for MSMs 44% (15; 63) 96% (73; 99) Treatment for prevention Truvada for heterosexuals 63% (22; 83) Truvada for women 0% (-69; 41) Tenofovir gel (daily) for women 15% (-20; 40) Truvada for women 0% (-50; 30)

4 Stable, healthy, serodiscordant couples, sexually active CD4 count: 350 to 550 cells/mm 3 Primary Transmission Endpoint Virologically-linked transmission events Primary Clinical Endpoint WHO stage 4 clinical events, pulmonary tuberculosis, severe bacterial infection and/or death HPTN 052 Study Design Immediate ART CD Delayed ART CD4 <250 Randomization

5 10,838 Individuals Screened Immediate Arm 886 Couples Delayed Arm 877 Couples Major reasons for exclusion: 3058 HIV+ but CD4 count out of range 2565 HIV- but HIV+ partner ineligible 308 Seroconcordant couples 155 Ineligible due to sexual history HPTN 052 Enrollment 1763 Couples (3526 Individuals) Randomized

6 HPTN 052 Enrollment (Total Enrollment: 1763 couples) U.S. Brazil South Africa Botswana Kenya Thailand India Americas 278 Africa 954 Asia 531 Zimbabwe Malawi

7 Total HIV-1 Transmission Events: 39 HPTN 052: HIV-1 Transmission Linked Transmissions: 28 Unlinked or TBD Transmissions: 11 p < Immediate Arm: 1 Delayed Arm: 27 18/28 (64%) transmissions from infected participants with CD4 >350 cells/mm 3 23/28 (82%) transmissions in sub-Saharan Africa 18/28 (64%) transmissions from female to male partners

8 One Transmission Event on ART Single Genome Analysis: 1-2 viruses transmitted Analysis of Transmission: >50 days earlier (84 – 190 days) -14 Screening Days0 Enrollment 1 Index begins ART AZT/3TC/EFV 28 Index VL< Partner HIV+ (WB) Partner VL < 400 Index CD4 = 482 Index VL = 87,202

9 HIV Treatment Guidelines GuidelineRecommended CD4 at start of therapy WHO (2013)< 500 BHIVA (2013)< 350 Respect decision if patient wants to start to reduce transmission DHHS - USA (2012)All irrespective of CD4 count IAS (2012)All irrespective of CD4 count EACS (2013)<350 Consider 350 – 500 and >500

10 Reducing onward transmission: Viral suppression among key population groups living with HIV in the United Kingdom. 19th Annual Conference of the British HIV Association (BHIVA) April 2013, Valerie Delpech, Alison Brown, Stephano Conti, Venkata Polavarapu, Zing Yin

11 Distribution of viral load among gay men living with HIV in the UK in 2010 HIV treatment as prevention among men who have sex with men in the UK: is transmission controlled by universal access to HIV treatment and care? AE Brown*,ON Gill, VC Delpech, Article first published online: 28 July 2013, HIV Medicine, Volume 14, Issue 9, pages 563–570, October 2013

12 Phillips AN, Cambiano V, Nakagawa F, Brown AE, et al. (2013) Increased HIV Incidence in Men Who Have Sex with Men Despite High Levels of ART-Induced Viral Suppression: Analysis of an Extensively Documented Epidemic. PLoS ONE 8(2): e doi: /journal.pone Reconstruction of HIV incidence from 2000 B: All condom use ceased C: ART provided at diagnosis

13 What is the potential impact of starting treatment early? ART started at CD4 <500 could have reduced the proportion of PLWHIV with detectable viraemia from 42% to 38% Halving the undiagnosed population could have led to to a decrease to 28% “Unlikely early treatment will reduce HIV transmission unless undiagnosed population is substantially reduced” Brown et al AIDS 2014 Jan 14;28(2):281-3

14 What is the potential impact of starting treatment early? Extending ART to all diagnosed HIV infected MSM with CD4 <500 in 2010 would reduce proportion of infectious men from 35% – 29%. Halving the proportion who are undiagnosed would further reduce this to 21% “The effectiveness of treatment as prevention will be limited unless the undiagnosed population is reduced through frequent HIV testing and consistent condom use” Brown et al AIDS 2014 Jan 14;28(2):281-3

15 Can we afford it? Estimated annual population treatment and care costs: – £104 million in 1997 – £483 million in 2006 – £721 million in 2013 Mandalia et al PLoS One 2010; 5:e15677

16 Summary: TasP The best evidence for effectiveness of an intervention to reduce transmission Effectiveness depends on knowing HIV status and therefore interlinked with testing strategies Cost may prohibitive

17 With limited resources do we focus on: ART for HIV positive people? ART for HIV negative people? Reduced transmission ?cost ?adherence ?sexual behaviour ?other STIs Reduced transmission ?cost ?adherence ?sexual behaviour ?other STIs Reduced transmission Reduced morbidity Reduced mortality Better quality of life Low pill burden Low toxicity Reduced transmission Reduced morbidity Reduced mortality Better quality of life Low pill burden Low toxicity


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